Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Thursday, October 31, 2013

There are those in the field of health IT who see every health IT-related mishap as an "anecdote" - the "anecdotalists" - and every "positive" study, no matter how weak, as "solid evidence" of the technology's beneficence and efficacy.

System errors with Victoria's trouble-plagued health technology program have caused more than 100 medication mix-ups at two Melbourne hospitals and need to be fixed urgently, the state's Auditor-General has found.

... Auditor-General John Doyle said problems at three hospitals were putting patients at risk of missing prescribed medications or receiving incorrect doses, in a report tabled in Parliament on Wednesday.

[Note: the full government audit report is available at http://www.audit.vic.gov.au/reports_and_publications/latest_reports/2013-14/20131030-clinical-ict-systems.aspx in fulltext and PDF. Other risks besides medication errors were found. The general problems it reports in the Victoria health IT program were written about here since 2004 and at my Drexel site since 1998 - poor planning and an inadequate understanding of
system requirements, underestimated project scope,
costs and time lines, as well as underestimations of the required clinical workflow
redesign and change management efforts. More on this in a future post.]

Problems included HealthSMART recording patients as having being discharged when they had only moved within the hospital, and difficulties for doctors in recording complex medications in the system.

Mr Doyle said a voluminous medication list meant doctors sometimes [picked whatever was easy -ed.] [and] printed out an incorrect prescription and then changed it manually, resulting in an inaccurate electronic record.

The doctors likely did this on order to be able to actually see patients and not fiddle with the computer incessantly.

He said incident reports at two hospitals had recorded "more than 100 reported incidents of missed or nearly missed medication, as well as medicines being administered at a higher dose than prescribed".

They included incidents in which "pain relief, antibiotics and other medication were given twice or not at all due to this issue".

That's a good way to injure or kill people. Trust me, I know - personally.

... He said hospitals had put manual measures in place to mitigate risks but they were not fail-safe, created inefficiencies and did not provide a long-term solution.

Workarounds always introduce new risk. I also remind that one should never need to work around something that's not in your way.

"As a result, there is continuing potential risk to patient safety that needs to be closely monitored by both [the Victorian Health Department] and the relevant health services," he said.

Health Minister David Davis said this week that Victoria had "learnt the lessons from the flawed HealthSMART program" and promised that hospitals and health professionals would have more say on future projects, which would be based on sound business cases.

In my view we don't need non-clinician hospital management (including and especially the business computing personnel) to "have more say", we need the health professionals to predominantly have that role.

For those who've never completed medical/nursing school nor completed a medical internship/residency/practice, only the exceptional can comprehend the true complexities of healthcare and health IT to support it [see note 1]. As observed in "Hiding in plain sight: What Koppel et al. tell us about healthcare IT", Nemeth & Cook, Journal of Biomedical Informatics 38 (2005) 262–263 at http://www.wapatientsafety.org/downloads/article-8.pdf:

... On the surface, healthcare work seems to flow smoothly. That is because the clinicians who provide healthcare service make it so. Just beneath the apparently smooth-running operations is a complex, poorly bounded, conflicted, highly variable, uncertain, and high-tempo work domain. The technical work that clinicians perform resolves these complex and conflicting elements into a productive work domain. Occasional visitors to this setting see the smooth surface that clinicians have created and remain unaware of the conflicts that lie beneath it. The technical work that clinicians perform is hiding in plain sight.

Those who know how to do research in this domain can see through the smooth surface and understand its complex and challenging reality. Occasional visitors cannot fathom this demanding work, much less create IT systems to support it.

It's becoming clearer the "anecdotalists" were quite wrong about health IT and its propensity to cause or contribute to medical error, especially when done poorly, i.e., is bad health IT which is all too common. I attribute this to conflict of interest and fairy tale views about IT.

Good Health IT ("GHIT") provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, can be easily, substantively and cost-effectively customized to the needs of medical specialists and subspecialists, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes.

Tuesday, October 29, 2013

Back in March, 2013, we discussed a lawsuit initiated by the then Mayor of Pittsburgh that challenged the tax-exempt, non-profit status of giant hospital system UPMC. The suit charged that UPMC functions more like a for-profit corporation based on its large surplus (recently $1 billion), larger reserves ($3 billion), minimal commitment to charitable care, and generous executive pay (recently $5.9 million to CEO Jeffrey Romoff, 19 executives paid more than $1 million, and ownership of a jet aircraft). By the way, Romoff's latest total compensation was said to be $6.1 million (look here), and UPMC just bought an even fancier corporate jet, a Bombardier Global Express worth $51 million (look here).

The Employees Vanish

The Pittsburgh Post-Gazette just described UPMC's remarkable response to the lawsuit.

The question is central to the city's suit to strip UPMC of its
status as a purely public charity. UPMC argues the city can't challenge
its exemption from payroll taxes because it technically has no
employees. It's a case where the legal reality may differ significantly
from the one that UPMC, which on its website claims to have 55,000
employees, markets on a regular basis.

This is not the first time UPMC has made this claim in response to a legal action,

Earlier this year, when UPMC faced 80 complaints of unfair labor
practices, it argued that it was only a holding company and did not
technically employ those in the complaints. The complaints alleged,
among other things, that UPMC employees were being punished for
attempting to unionize. UPMC ultimately settled.

Obvious Contradictions

These claims of invisible employees appear to be contradicted by UPMC's own public relations,

UPMC touts it large workforce. Its 2012 annual report, for example: 'The economic impact of UPMC is more substantial than most people
realize. The organization is the largest nongovernmental employer in the
Commonwealth of Pennsylvania, and more than $6.2 billion in total labor
income can be attributed directly or indirectly to UPMC.'

UPMC's website and media releases say the hospital giant employs in
the range of 55,000 people. And when UPMC made the top rankings of U.S.
News & World Report's Best Hospitals, it did so as a conglomeration
of several facilities attorneys are now arguing are separate
subsidiaries.

Also,

[An attorney representing the city of Pittsburgh, Ronald] Barber argued that even for tax purposes, UPMC has documented having
employees. In a Form 990 filed for the 'UPMC Group,' the hospital
network said it employed around 52,000 people.

A few days later, the Post-Gazette reported that the city responded to these UPMC claims in matter-of-fact way,

On its website, in its annual report and in some tax filings, UPMC
purports to have employees -- sometimes tens of thousands of them, the
city of Pittsburgh's attorneys said in a court filing.

Furthermore,

The city also argued that those working for subsidiaries are UPMC
employees as well, pointing to UPMC's 2012 Annual Report and website,
which tout the hospital system as one of the state's largest employers.
Attorneys also pointed to a lawsuit in which UPMC claimed to 'extend
offers of employment.'

How Complexity Benefits Bureaucrats and Managers

It is Halloween coming up, not April Fool's Day, and the claims made on behalf of UPMC do not appear to be jokes. Instead, I believe they underline two serious problems with how large health care organizations are currently lead.

The first is that health care organizations often have exceedingly complex structures for reasons that have nothing to do with fulfilling their health care mission. One reason may be that the complexity creates options for plausible deniability. In particular, when such organizations are accused of bad behavior, as they now often are, subsidiaries may be set up to "take the rap." For example, we discussed how Pfizer Inc has been using the bankruptcy filing of its Quigley subsidiary made as if that subsidiary were independent to delay resolution of claims that the subsidiary sold hazardous asbestos products.

This tactic of having the subsidiary take the rap may be particularly useful when taking the rap may lead to a severe penalty for the organization, such as disbarring it from being paid by the government. A disbarred subsidiary may simply be dissolved and its work transferred to other parts of the organization. For example, in May, 2013 we discussed a settlement in which Baush and Lomb subsidiary Ista Pharmaceutical would be disbarred from participation in government programs. However, Baush and Lomb itself would not be disbarred, and would be able to "wind down" Ista's operations and transfer its products to other parts of the larger company.

The current example appears to be a more creative use of subsidiaries to claim deniability, although whether the arguments about disappearing employess above are even plausible is open to question.

Complex organizations also offer many opportunities to employ and enrich administrators, bureaucrats and managers, and to justify ever larger compensation for the top executives who purport to run the whole thing. That such proliferation of management and management compensation may detract from the mission does not appear to be a big concern of the sorts of people who now run health care.

Contempt for Truth

The second problem is that the leadership of large organizations seem to have little use for the truth. Instead, they may put lots of faith in their marketers, public relations people, and legal staff to obfuscate the truth in pursuit of ever more revenue and executive enrichment. As management becomes less and less reality-based, however, it may be less likely to be able to respond to the very reality-based needs of patients and the public.

Conclusion

I hope that the outlandish claims now being sanctioned by UPMC leadership may raise awareness of what is going wrong with the leadership of health care organizations in general. As we have been saying for years, health care leadership that puts its self-interest ahead of patients and the public, and which disregards the truth in service of self-interest may be the biggest cause for ever increasing health care costs, and ever declining access and regard for the health of patients and the public. True health care reform would encourage leadership that puts the mission ahead of self-interest, and values honesty more than personal profit. It would promote regulation that holds top leadership of organizations accountable for their organizations' actions and not allow the leadership to hide behind complex organizational structures.

This remarkable and unprecedented regulatory accommodation is based on nebulous, speculative and largely imaginary grounds that translate to - just because:

... (c) Sense of Congress.--It is the sense of the Congress that--
(1) clinical software and health software (as defined in
section 201(tt) of the Federal Food, Drug, and Cosmetic Act, as
added by subsection (a)) [can]--
(A) advance the goals of enhanced patient safety and continued innovation;
(B) hold much promise to lower costs and improve
the health of patients; and
(C) can improve the quality and efficacy of health
care provider services

You observe that the true political
goal is socialized medicine facilitated by health care information
technology. You note that the public is being deceived, as the rules
behind this takeover were stealthily inserted in the stimulus bill.

I have a different view on who is deceiving whom. In fact, it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants.

For
£12.7 billion the U.K., which already has socialized medicine, still
does not have a working national HIT system, but instead has a major IT
quagmire, some of it caused by U.S. HIT vendors. [That project, the National Programme for IT in the NHS or NPfIT, was since abandoned - ed.]

HIT (with a few
exceptions) is largely a disaster. I'm far more concerned about a
mega-expensive IT misadventure than an IT-empowered takeover of
medicine.

The stimulus bill, to its credit, recognizes the need
for research on improving HIT. However this is a tool to facilitate
clinical care, not a cybernetic miracle to revolutionize medicine. The government has bought the IT magic bullet exuberance hook, line and sinker.

I can only hope patients get something worthwhile for the $20 billion.

The launch of HealthCare.gov
certainly didn’t go as planned. Due to technical errors, millions of
Americans were sent to the functional equivalent of a waiting room
before they could enter the shopping portion of the site.

Historically, projects of such complexity and demand have encountered
early problems yet still often achieve great success. While much of the
commentary has focused on coding problems, the site still has the
potential to spur innovation — be it public or private — that will
result in quality improvement and lower costs.

(Note the definitive "will", without evidence. Mr. Obama's probably been hearing a lot of non-evidence-based wishful thinking about health IT in recent years.)

The majority of information systems developments are unsuccessful. The larger the development, the more likely it will be unsuccessful. Despite the persistence of this problem for decades and the expenditure of vast sums of money, computer failure has received surprisingly little attention in the public administration literature. This article outlines the problems of enthusiasm and the problems of control, as well as the overwhelming complexity, that make the failure of large developments almost inevitable. Rather than the positive view found in much of the public administration literature, the author suggests a pessimism when it comes to information systems development. Aims for information technology should be modest ones, and in many cases, the risks, uncertainties, and probability of failure mean that new investments in technology are not justified. The author argues for a public official as a recalcitrant, suspicious, and skeptical adopter of IT.

Article start:

The majority of information systems (IS) developments are unsuccessfu1. The larger the development, the more likely it will be unsuccessful.

Though the exact numbers are uncertain and depend to some extent on how success is measured, something like 20 percent to 30 percent of all developments are total failures in which projects are abandoned. Around 30 percent to 60 percent are partial failures in which there are time and cost overruns or other problems. The minority are those counted as successes (Collins and Bicknell 1997; Corner and Hinton 2002; Georgiadou 2003; Heeks and Bhatnagar 1999; Heeks 2002, 2004 ; Iacovou 1999; James 1997; Korac-Boisvert and Kouzmin 1995 ; Standish Group 2001, 2004).

A U.S. survey of IS projects conducted by the Standish Group in 2001 found that success rates varied from 59 percent in the retail sector to 32 percent in the financial sector, 27 percent in manufacturing, and 18 percent in government. Overall, the success rate was 26 percent. In all, 46 percent of projects had problems, including being over budget and behind schedule or being delivered with fewer functions and features than originally specified. Another 28 percent failed altogether or were cancelled. Cost overruns averaged nearly 200 percent. Th is success rate varied dramatically by total project budget: For projects under US$750,000 the success rate was 55 percent; for those with budgets over US$10 million, no projects were successful (SIMPL/NZIER 2000).

More recent Standish Group (2004) estimates saw a success rate of 29 percent, but 53 percent of projects had problems and 18 percent failed. A New Zealand government study judged 38 percent of government projects a success, while 59 percent involved problems and 3 percent were a complete failure or were cancelled. Government success rates, at 31 percent, were slightly higher than private sector success rates. Above the NZ$10 million mark, however, the success rate for both was zero (SIMPL/ NZIER 2000). One study of hundreds of corporate software developments found that five out of six projects were considered unsuccessful, with one-third cancelled outright. Of the two-thirds that were not cancelled, price and completion times were almost twice what had originally been planned (Georgiadou 2003). The Royal Academy of Engineering and the British Computer Society (2004) found that 84 percent of public sector projects resulted in failure of some sort.

The sums involved in such projects can be staggering. A study of IS developments in the British public sector estimated that 20 percent of expenditures were wasted, and a further 30 percent to 40 percent led to no perceivable benefits (Wilcocks 1994). In 1994, the U.S. General Accounting Office reported that spending of more than US$200 billion in the previous 12 years had led to few meaningful returns.

The article is extensively referenced, and nothing has changed since it was published. While the article's cost from the jstor.org site is $25 (US I think), it is well worth reading for anyone involved in large public sector IT projects.

Especially, the President of the United States and his staff.

It is my belief the same actors who've misled him about health IT and the supposed ease of building a national insurance portal for 300 million+ people are going to mislead him about remediation of the latter, resulting in yet more embarrassment, and perhaps eventually patient harm and death when someone, somewhere, is denied care or has delayed care due to insurance loss.

Sunday, October 27, 2013

Omnicare, Inc, a
leading U.S. provider of pharmacy services to the elderly, has agreed
to pay the U.S. government $120 million to settle allegations the
company gave nursing homes steep discounts on prescription drugs in
exchange for patient referrals.

Cincinnati-based
Omnicare announced the settlement on Wednesday in a filing with the U.S.
Securities and Exchange Commission, but denied any wrongdoing. The
lawsuit, filed in 2010 by former Omnicare employee Donald Gale, had been
scheduled to go to trial on October 28.

Gale
accused the company of engaging in a kickback scheme called 'swapping'
in which Omnicare allegedly gave nursing homes heavily discounted
prescription drugs for inpatients covered by Medicare Part A. That
federal benefit program pays skilled nursing facilities a fixed fee per
patient, per day, for the first 100 days of a patient's stay, according
to court filings.

In exchange, the nursing homes allegedly referred their
other patients, many covered by other federal benefit programs, allowing
Omnicare to bill the full price of their prescription drugs and
pharmacy services, the lawsuit said.

As is usually the case,

Omnicare's vice president of investor
relations, Patrick Lee, said in an emailed statement that the company
did not admit liability in settling the lawsuit.

'The
Company agreed to settle the matter in order to avoid continued
litigation and to focus on its mission of helping to ensure the health
of seniors and other patient populations in a cost-effective manner,' he
said.

He did not comment on the discrepancy between the alleged kickback scheme apparently meant to increase company revenue and that bit about ensuring health in "a cost-effective manner."

Will There be Still Others?

In addition, the Cincinnati Business Courier quoted another Omnicare executive,

'This settlement is not an admission of liability, and Omnicare continues to deny that there was any wrongdoing,' Robert Kraft,
chief financial officer for Omnicare, said Wednesday in a conference
call with market analysts regarding the company’s third-quarter
earnings. 'When we agree to settle these types of matters, we have and
will continue to make decisions in the best interest of our
shareholders. …'

'We operate in a highly regulated industry, and we believe additional
matters will likely arise against the company in the future,' Kraft
said. 'We believe the matters of which we are now aware, including the
aforementioned settlement, are manageable given the company's financial
position and cash-flow characteristics.'

Was that an admission that the company often violates regulations? It is hard to tell. However, it is clear that this is not the first settlement of allegations of bad behavior that the company has made.

In addition, as we discussed in 2010, in 2009, we discussed
a $98 million settlement made by Omnicare, US based corporation that
manages pharmacy-benefits, of allegations that it received kickbacks
from generic drug manufacturers for buying and recommending their
drugs. Omnicare had previously submitted to a corporate integrity
agreement in 2006, and paid $102 million to settle allegations it
defrauded Medicaid.

So the count so far is four settlements for a total of approximately $337 million, and one corporate integrity agreement.

Summary

So Omnicare is yet another of the many large health care organizations which have been subject to various legal actions suggesting diverse kinds of bad behavior. Omnicare, like many of these, has paid penalty upon penalty, yet each settlement seems to be made in a vacuum without reference to prior events. Furthermore, almost no settlement, and no settlement made by Omnicare, ever either imposed a large enough penalty on the company to deter further problems, or imposed any - I repeat any - negative consequences on anyone at the company who authorized, directed, or implemented the bad behavior. So, as obliquely stated by the Omnicare CFO in this case, expect further "matters" to be addressed in the future.

the usual sorts of legal settlements we
have described do not seem to be an effective way to deter future
unethical behavior by health care organizations. Even large fines can be
regarded just as a cost of doing business. Furthermore, the fine's
impact may be diffused over the whole company, and ultimately comes out
of the pockets of stockholders, employees, and customers alike. It
provides no negative incentives for those who authorized, directed, or
implemented the behavior in question. My refrain has been: we will not
deter unethical behavior by health care organizations until the people
who authorize, direct or implement bad behavior fear some meaningfully
negative consequences. Real health care reform needs to make health care
leaders accountable, and especially accountable for the bad behavior
that helped make them rich.

Friday, October 25, 2013

Here we go again. After a hiatus during which the US media and perhaps parts of the
government were preoccupied with such issues as the ongoing controversy
over health care reform, and a government shutdown apparently arising
out of this controversy, the march of legal settlements involving big
health care organizations has resumed.

In alphabetical order,...

Boston Scientific

From the Minneapolis Star-Tribune on 17 October, 2013, an account of a settlement arising from alleged misbehavior that started in 2002,

A $30 million settlement between the U.S. Department of Justice and
Boston Scientific will likely end a case involving the sale of defective
heart devices from 2002 through 2005 by subsidiaries Guidant, Guidant
Sales and Cardiac Pacemakers.

Note that the allegations were particularly egregious since they involved a company selling products they knew to be defective in ways that could prove fatal as if they were quite safe,

The settlement closes a fraudulent-claims lawsuit that
alleged Guidant knowingly sold defective implantable defibrillators to
health care facilities that implanted them into thousands of Medicare
patients.

In particular,

The government’s complaint said that Guidant knew as early as April
2002 that its Prizm 2 line of devices was defective and knew in November
2003 that its Renewal 1 and 2 devices were capable of short-circuiting
and delivering an electric shock that 'arcs' back onto the device
instead of being directed to an irregularly beating heart.

According to Boston Scientific’s website, 83 malfunctions
and nine reported deaths have been connected with the Renewal devices
and 40 confirmed malfunctions and five patient deaths have been
associated with the Prizm devices. About 500 Renewal devices remain
implanted worldwide; about 1,400 Prizm devices remain in patients,
according to the website.

Although Guidant took action to fix the defects, the
government alleged that the company continued to sell its remaining
stock of the old, defective versions of the devices. In fact, federal
officials say that as Guidant learned about the cause of the defect, it
took steps to hide the problem from patients, doctors and the Food and
Drug Administration.

According to the government, Guidant did not fully
disclose the problem until May 2005, when two Minneapolis doctors
publicly aired their concerns about one of the defibrillators after it
failed to revive a 21-year-old Grand Rapids, Minn., patient. Guidant
later admitted it had known for three years that the device could
short-circuit, but chose not to alert doctors or the public.

This is only the latest settlement made by Boston Scientific since 2005,

Boston Scientific paid $27.5 billion to acquire Guidant in 2006. It
has been paying quite a bit since in relation to Guidant’s defective
defibrillators.

In 2007, Boston Scientific paid $240 million to settle
claims with thousands of patients who had sued Guidant after the
defective devices were recalled. Later, in February 2010, Guidant
pleaded guilty to misleading the FDA about problems with the devices and
paid a fine of $296 million.

In fact, the then case of the allegedly concealed implantable cardiac defibrillators (ICD) was one of the first cases of apparently unethical health care corporate management behavior leading to bad patient outcomes we discussed on Health Care Renewal. (Look here for a more recent summary of this case.)

Yet despite the fact that this apparently deeply unethical conduct lead to patient deaths, no individual who authorized, directed or implemented the bad behavior has suffered any negative consequences for it over the eight years since the details first became public.

One physician who helped bring this case to light was also apparently concerned about the impunity of those responsible,

Dr. Robert Hauser, one of the doctors who went public back in 2005, criticized the settlement on Thursday.

'The $30 million should have little impact on their
business,' Hauser said in an e-mail. 'I find it very disturbing that
such a small settlement was accepted by the DOJ in view of the magnitude
of wrongdoing by Guidant management.'

Stryker Corp

This week, MLive.com reported on another settlement involving allegations of unethical behavior by a device company dating back to 2003,

An investigation by federal authorities found that
Stryker Corp. subsidiaries in five foreign countries made illicit
payments and tried for several years to bribe doctors, health care
professionals and government-employed officials in order to obtain or
retain business.

Stryker has agreed to pay more than $13.2 million to settle the charges.

The SEC charged the Kalamazoo-based medical technologies company with violating the Foreign Corrupt Practices Act,
alleging that its subsidiaries in Argentina, Greece, Mexico, Poland and
Romania made illicit payments totaling approximately $2.2 million 'that
were incorrectly described as legitimate expenses in the company’s
books and records.'

The SEC said descriptions of the payments varied from a charitable
donation to consulting and service contracts, travel expenses, and
commissions.

The SEC states that Stryker made about $7.5 million in illicit
profits as a result of the improper payments. It did not specify during
what year all of the events occurred, but indicated some as far back as
2003.

Note that the payments seemed deliberately designed to corrupt health care professionals and managers, for example,

According to the SEC’s order, Stryker’s subsidiary in Greece made a
purported 'donation' of nearly $200,000 in 2007 to a public university
in Greece to fund a laboratory that was a pet project of a public
hospital doctor. In exchange for the payment, the doctor agreed to
provide business to Stryker.

Also,

The SEC stated that its investigation also found that Stryker
subsidiaries bribed foreign officials by paying their expenses for trips
that lacked any legitimate business purpose.

'For example, in exchange for the promise of future business from the
director of a public hospital in Poland, Stryker paid travel costs for
the director and her husband in May 2004,' according to the SEC. 'This
included a six-night stay at a New York City hotel, attendance at two
Broadway shows, and a five-day trip to Aruba.'

As in the case above, it appears that no individual who authorized, directed or implemented the questionable payments will suffer any negative consequences. In fact, as is usual in such cases,

The settlement does not not require Stryker to admit or deny the allegations,...

However, an SEC official did say,

Stryker’s misconduct involved hundreds of improper payments over a
number of years during which the company’s internal controls were
fatally flawed. Companies that allow corruption to occur by failing to
implement robust compliance programs will not be allowed to profit from
their misconduct.

While Health Care Renewal has not discussed this particular case before, it is hardly the first case of bad conduct by Stryker that we have discussed. In the past we noted
- In 2012, a Stryker subsidiary pleaded guilty to misbranding in response to allegations that its marketers conspired to defraud physicians in order to sell a product to promote bone growth that proved harmful to patients (look here).
- In 2010, Stryker settled a case alleging unfair and deceptive sales practices again used for bone growth accelerators (look here).
- In 2009, some apparently low-level Stryker employees pleaded guilty to promoting off-label use of these same products (look here).
- In 2007, Stryker made an agreement allowing federal supervision after charges one of its units had violated anti-kickback laws when making supposed "royalty" payments, often huge, to orthopedic surgeons in connection with its production of prosthetic hips and knees. Several other device companies signed deferred prosecution agreements, and as a result, for a time all had to make public their payments to doctors and various non-profit organizations. (See summary here.)

Summary

This recent crop of settlements has some features in common. The settlements involved multinational device companies. The settlements occurred at least a decade after the alleged bad behavior started. The settlements required only small payments - at least on a corporate scale -from the companies involved, but no negative consequences for anyone who authorized, directed, or implemented the bad behavior. Finally, the settlements were made by companies who had striking past records of previous settlements of bad behavior.

The march of legal settlements demonstrates the pervasiveness of unethical behavior, often involving harm to patients or sullying of health care professionals, involving large, rich health care corporations. It also demonstrates the impunity of the top leaders of such corporations who often make huge amounts of money despite, or perhaps because of their companies' misconduct. Despite intermittent threats by US government officials to get tough with unethical behavior by health care corporations, this pattern has continued for years, as we have documented.

True health care reform would hold leaders of health care organizations accountable for their organizations' behavior, and its effects on patients and health care professionals.

Friday, October 18, 2013

Our latest example of the interchangeability of top insiders within corporate health care and the government agencies that are supposed to regulate corporate health care comes via an announcement from Johnson and Johnson,

Johnson & Johnson (NYSE: JNJ) announced today that Mark B. McClellan, M.D., Ph.D., Senior Fellow in Economic Studies, and Director of the Initiative on Value and Innovation in Health Care, Brookings Institution, will join the Board of Directors on October 15, 2013. Dr. McClellan will serve on the Regulatory, Compliance & Government Affairs Committee and the Science, Technology & Sustainability Committee of the Board.

As former commissioner of the U.S. Food and Drug Administration (FDA) from 2002 to 2004, and as the former administrator of the Centers for Medicare & Medicaid Services for the U.S. Department of Health and Human Services
from 2004 to 2006, Dr. McClellan has more than two decades of public
service and academic research experience. From 2001 to 2002, he served
as a member of the President's Council of Economic Advisers and senior director for health care policy at the White House. During President William J. Clinton's administration, Dr. McClellan held the position of deputy assistant secretary of the Treasury for economic policy.

So Dr McClellan has gone from running the US Food and Drug Administration, the primary government regulator of the pharmaceutical industry, to stewardship of one of the biggest pharmaceutical (and biotechnology and device) companies.

Not noted in that announcement was that Dr McClellan has been collecting positions in health care corporations since at least 2009. The examples I found included in chronological order:

2009 - General Atlantic LLC

This appears to be a private equity firm which claims to be a "leading global investment firm."

Notably, I did not see anything in any of these firms' announcements about Dr McClellan or their biographies of him that noted his board or advisory committee positions with other firms.

Summary

Dr Mark McClellan rose through the ranks in the US executive branch ending with positions as FDA commissioner and administrator of the Center for Medicare and Medicaid Services (CMS) within the Department of Health and Human Services (DHHS). He served under two presidents, Clinton and George W Bush. Within 3 years of exiting DHHS, he picked up his first important commercial position, at General Atlantic LLC, and then added other positions with Capital Royalty, Castlight Health, AvivReit, and now the biggest of all, Johnson and Johnson. Meanwhile he apparently continues at the Brookings Institution. He must be one very busy man.

This case could be lumped with those of another former FDA commissioner and Secretary of Health and Human Services who ended up as a Director of Medtronic (see this post), another Secretary of DHHS who ended up on the boards of multiple health care corporations (see this post), a director of the National Institutes of Health (NIH) who became a Sanofi executive, etc, etc (see this post).

While some might argue whether his acquisition of a leading advisory position with a private equity firm three years after he left DHHS technically constituted a spin through the revolving door, Dr McClellan's cumulative acquisition of four more such positions within the following four years certainly demonstrates how our corporate dominated health care system and the government agencies which are supposed to be regulating it to assure the health and safety of patients, and the maintenance of the public health seem to be run by an interchangeable cast of insiders. We have asked before whether we can trust federal regulators to put patients' and the public's health first when they know they could easily become candidates for lucrative private positions in the companies they regulate, or which are affected by their regulations, presumably assuming they have not done too much during their time in government to offend the leaders of such companies.

We have noted that the system in which government and big corporations largely overlap in terms of their leadership and presumably goals is called corporatism. One can argue that such systems end up being run primarily for the benefit of corporate and government insiders.

Until we dispel the fog of corporatism that has spread over the
government that was once supposed to be of the people, by the people,
and for the people, expect no real health care reform, and expect
continuing rising costs, declining access, and worsening patient care.
Obviously, true health care reform would start with the government and
its officials putting patients' and the public's health first, way ahead
of the financial comfort of corporate leaders.

I would note that neither the currently controversial and now operational Affordable Care Act, nor any of its opponents schemes for alternatives addresses this issue.

Wednesday, October 16, 2013

A new and very interesting EMR "glitch" from a report I received recently:

... I found a glitch with my [name redacted] EMR. It probably happens with all EMRs. I had a patient on primidone (http://en.wikipedia.org/wiki/Primidone) for essential tremor. Later, his primary
care put her on warfarin [a "blood thinner" - ed.] for atrial fibrillation. Some time after that, I took her off
of primidone. Her INR jumped to 7 or 8. [High - ed.] What happens is that the EMRs
warn a physician pretty well if you START a
medicine that interacts with warfarin, but fails to warn if you STOP a
medicine that interacts with warfarin. If you are used to relying on
your EMR to warn you about drug interactions, you can fall into this
trap easily, as I found out. Luckily, the patient
was not harmed.

In other words, if a medication that interacts with another medication by suppressing the latter's effects to some degree is discontinued, EMRs may not warn of it. Stopping the former can accentuate the effects of the latter, and disaster can result. A primidone metabolite, phenobarbital, decreases INR and the anticoagulant effects of warfarin (http://www.medscape.com/viewarticle/745645_3). Stop primidone, but continue warfarin, and ... wham.

The alert algorithms were apparently not designed with this eventuality in mind ... probably because the designers never thought of this issue. Medicine is not as easy as it might appear to the outside, non-expert observer.

We recently wrote about for-profit medical schools located offshore from the US, but catering to American students, not students from the countries in which they operate. Now some new media reports raise further questions, if not mysteries about another set of such schools.

Two Bloomberg articles on a trial underway focused on the alleged use of offshore accounts to avoid US taxes. These accounts were connected to the former long-term President and founder of two offshore medical schools, and his spouse, a dean at one of the schools.

Patricia Hough, according to her
lawyers, is an altruistic psychiatrist who helped her husband
build two Caribbean medical schools. To prosecutors, she is a
tax cheat who used offshore accounts to avoid paying taxes on
millions of dollars from the schools’ sale.

Jury selection began today in federal court in Fort Myers, Florida, where Hough, 67, is accused of using accounts at UBS AG, the largest Swiss bank, and elsewhere to hide assets and
income from the Internal Revenue Service, including almost
$34 million she and her husband made when the schools were sold
in 2007.

The Bloomberg article asserted,

At the heart of the case is
whether she misused accounts associated with the Saba University
School of Medicine Foundation.

The main question to me is not whether Dr Hough is guilty or innocent, which I cannot tell. There are more intriguing mysteries raised by this case.

How Did Non-Profit Medical Schools Become For-Profit?

According to Bloomberg,

Hough’s lawyers say she helped [her husband, David] Fredrick build Saba
University School of Medicine, on the island of Saba in the
Netherland Antilles, and the Medical University of the
Americas, or MUA, on Nevis in the West Indies.

To do so,

Through the Saba foundation, which they first funded
in 1988, according to a government trial brief filed Oct. 3, the
couple opened the Saba University School of Medicine in 1993.
Fredrick served as president and a foundation director. Hough
was associate dean for clinical medicine.

Also,

In 1999, Fredrick and Hough began the Medical University of
the Americas, a for-profit school on Nevis in the West Indies,
according to the government filing.

There seems to be no question that the schools were started by a foundation based in the Netherland Antilles. A report of a site visit
of the Saba University School of Medicine by the Division of Licensing
of the Medical Board of California in 2004 summarized this history,

In
1986, the government of the Netherlands Antilles proposed to a group of
American educators that a medical school be established on the small
island of Saba, N.A. It was to be relatively small, of high quality and
established for the dual ppurpose of benefiting the economy of the
island (of only 1500 population) and attracting N.A. citizens to medical
careers in the N.A.

A committee of Dutch citizens
from Curacao, the seat of the N.A. government, approved the preliminary
plans and the school was founded as a non-profit foundation under Dutch
law....

The Saba University website still states that the school is accredited in the Netherlands,

Saba University School of Medicine’s Doctor of Medicine (M.D.) program is accredited by the NVAO
(in Dutch: Nederlands-Vlaamse Accreditatieorganisatie). The NVAO is the
Accreditation Organization of the Netherlands and Flanders. This
organization was established by international treaty and ensures the
quality of higher education in the Netherlands and Flanders.

So apparently Saba University was started as a non-profit organization meant to focus on medical education for the Netherlands Antilles, and thus accredited there. But then, somehow, according to Bloomberg.

Equinox Capital, a private-equity firm based in Greenwich,
Connecticut, bought the Saba school and MUA for $36 million in
2007. The transaction included $34 million for land held in the
name of Fredrick’s daughter from an earlier marriage, according
to prosecutors.

Hough and Fredrick didn’t tell the IRS about most of the
proceeds of the sale and transferred money among various
undeclared accounts to buy the plane and real estate, make gifts
to family members and pay personal expenses, prosecutors said.

Equinox Capital III, L.P. announced that it has completed the
recapitalization of Saba University School of Medicine B.V. ('Saba').
Founded in 1986, Saba is a leading for-profit university that awards
four-year graduate degrees in Doctors of Medicine (M.D.).

R3 Education is a
Massachusetts-based holding company that controls The Saba University
School of Medicine ('Saba'), The Medical University of the Americas
('MUA') and St. Matthew University ("SMU").

After,

Prairie Capital partnered with Equinox Capital to acquire the three universities.

It is enough to cause some dizziness. Let me recap. Mr Fredrick and
Dr Hough somehow founded two medical schools apparently under the auspices of a
foundation, the Saba University School of Medicine Foundation, which the
couple ran. The goal of the foundation was to attract Netherland
Antilles citizens to medical careers in the NA. However, the Saba
University school became an off-shore facility for US medical students.
The two schools were later acquired by Prairie Capital and Equinox
Capital, and they are now run as for-profit operations by R3 Education.

So somehow Saba University transitioned from being a non-profit meant to serve the medical education needs of the Netherlands Antilles to a for-profit owned by US private equity firms (and apparently now focused on serving Americans.)

How did that happen? What was the rationale for the change? Did any Dutch authorities consider the implications for their country? Did any American organizations concerned with the quality of education and credentials of US physicians consider the implications?

Where Did the Money Go?

According to Bloomberg, US prosecutors made some striking allegations,

Both the foundation and MUA failed to tell the IRS about
accounts held at UBS, Liechtenstein Landesbank and other banks,
the U.S. charges.

Singenberger and Luetolf helped the foundation and MUA move
money through British Virgin Islands or Hong Kong entities they
controlled called Top Fast Finance Ltd., Ample Dynamic Trading
Ltd., New Vanguard Holdings Ltd. and Apex Consultants Ltd.,
according to prosecutors.

'Hough and Fredrick were the beneficial owners of and had
signatory authority over all over these accounts and owned and
controlled each of them,' prosecutors said in their brief.

The prosecution also alleged that Mr Fredrick and Dr Hough spent the money they allegedly got from selling the two medical schools rather lavishly. Per the second Bloomberg article,

[Prosceutor] Kessler said Hough and her husband used the proceeds of the school sales
to buy a $1.6 million airplane, a $1.1 million house in Asheville, North Carolina, a $590,000 house in Greenville, North Carolina, and an $800,000
condominium in Sarasota, Florida. She said they also gave money to
relatives.

The prosecutors charged that the money the private equity firms paid went to Mr Fredrick and Dr Hough. But while Mr Fredrick was President of Saba University, and apparently ran the foundation that was supposed to support it, he did not own either. So why would the money go to him, and his wife? If the money did not go to them, where did it go?

Dan Saunders, an attorney for Hough, said his client never believed the
money held at UBS AG (UBSN), the largest Swiss bank, and in other
offshore banks belonged to her. Rather, he said, she thought it belonged
to the foundation that ran the schools.

'It wasn’t her money, and she never believed it was,' Saunders said in his opening statement.

If that is true, however, why is money that supposedly belongs to a foundation sitting quietly in a Swiss bank?

Dr Hough's lawyer said,

Saunders said the accounts did serve a business purpose: to protect the
assets of their nonprofit foundation from people attempting a hostile
takeover.

Hostile takeovers of publicly held corporations do occur, of course. However, how could a hostile takeover of a foundation occur, and who would possibly want or be able to do so?

So thus far, no one has offered a rationale explanation for how the schools were sold, why they were sold, and where the money resulting from the sale went.

Where in the World is Mr Fredrick?

So far, while the defendant is Dr Hough, the role of her husband, Mr Fredrick, apparently the President of Saba University from its founding at least until 2007, seems key. Yet little of the coverage focused on Mr Fredrick. The reason for that suggests the next mystery, per the first Bloomberg article,

Fredrick
vanished after the indictment, leaving Hough to face trial
alone. U.S. District Judge John Steele, who is overseeing the
trial, has declared Fredrick a fugitive.

So why did Mr Fredrick flea, and of course, where did he go?

Obviously, the fact that Mr Fredrick, who was the President of Saba University for many years, chose not to defend himself against charges that he hid the money he somehow obtained from the sale of that and another medical school, but rather fled, suggests that he may not have had a very good defense against those charges. What does that say about the leadership of these medical schools?

Summary

So the coverage of this intriguing trial, when added to some other publicly available information, suggests a wealth of mysteries about the founding, current nature, and leadership of two Caribbean medical schools which currently are run as for-profit firms and owned by US private equity firms, and whose student bodies come almost exclusively from the US.

So the really big mysteries are those about the implications for the medical education these schools provide, the students they attract, the physicians who graduate from their programs, the US patients of such physicians, and the US government which largely provides the loans which paid for these students' education (look here).

Despite the extraordinary nature of this case (again, involving the longterm president of an offshore medical school that sought to educate a substantial number of US physicians, and who is now a fugitive from justice), the only interest in it so far seems to be its implications for US prosecutions of hidden offshore accounts.

This case illustrates why we must reexamine our fascination for "market based" approaches to
health care, when almost nothing about any part of health care
resembles, or could resemble a free market (see this post). We need to
make health care more transparent, and shine more sunshine on the nooks
and crannies, like off-shore but US corporate owned medical schools. We
need to facilitate health care leadership and governance that puts
patients' and the public's health first, way ahead of the personal
enrichment of the participants.

ADDENDUM (29 October, 2013) - Dr Hough was convicted of defrauding the IRS and income tax evasion, see the Bloomberg article. So far I see no response, certainly no apology or disavowal, by the current managers and owners of the medical school.

I unfortunately could not make it Down Under for HIC2013 in Adelaide. However, HISA has posted videos of a number of presenters.

One of the presenters is Dr. Schaper. Her presentation "Health Informatics: A megatrend driving investment, careers & delivering the future of healthcare" is at http://www.hisa.org.au/page/hic2014videos (bottom video). It is well worth watching.

Louise Schaper PhD, CEO, Health Informatics Society of Australia

After reviewing the potential benefits of heathcare IT, Dr. Schaper asks what I consider the most critical question of all.

At 08:20 she asks: "What's missing from this [multi-billion dollar] investment?"

The answer is "Health Informatics."

Dr. Schaper then indicates the real-world implications of the field of commercial health IT largely missing its critical founding scientific discipline:

At 13:00 she amplifies the point further: We are not learning our lessons! The themes of that slide are familiar to readers of this blog, and to current health IT users:

Dr, Schaper then goes on to cover some real-world issues related to impediments to meaningful health informatician engagement in health IT design, implementation and other aspects of leadership.

The presentation is worth watching in its entirety. The issues in health IT of meaningful involvement and leadership by those with expertise in healthcare informatics (as compared to, for example, those in manufacturing, mercantile, and management computing whose experience is often ill-suited for high-level roles in healthcare projects) are truly international.

Finally, for those in the U.S. not used to Australian accents, Dr. Schaper's is quite enjoyable to listen to.

From the same people who brought us HITECH, the stimulus bill for rapid rollout of commercial electronic medical records, order entry, results reporting and other components of enterprise clinical "command and control" software for hospitals through which every transaction of care must pass.

First, a preamble: I once tried to alert a hospital where I'd trained decades before, Abington Memorial Hospital (http://www.amh.org/), of impediments to safe care I'd noted in their EHR's, predominantly their ED EHR. They did not listen. In fact, their response to my concerns was characterized by an apparent incompetence regarding conduct of safety investigations. For instance, to my written concern in an April 2010 letter to the CEO and CMO about the ED EHR that:

... I've also had to stop administration [to my mother] of an antibiotic (Levaquin) in the recent past in the ED that she has had an adverse reaction to (torn rotator cuff), despite my having told ED intake she was allergic to it. She relates that administration of Levaquin was then almost repeated on the floor until she herself refused it during that past admission.

This was the sworn testimony in May 2013 about the "investigation" that resulted, from the hospital's VP of Risk Management, Regina Sturgis:

A: Deborah [hospital General Counsel] asked me to investigate the Levaquin issue which I did.
Q: Did you do that on your own or did you delegate some of the --
A: No. I did it on my own.
Q: Do you know whether any of the IT folks were ever brought in to look at the -- the EMR issues referenced in this letter?
A: No, I do not. I know that I was asked to look at the Levaquin because of my clinical background.
Q: Okay. Did you come up with any conclusions?
A: Yes.
Q: What was your conclusion?
A: That she had been ordered Levaquin in the ETC [Emergency Trauma Center a.k.a. ED], that it had been discontinued about a very short period of time later, under a half an hour, and that she never received it.

So, the investigation of a complaint that family and then the patient themselves had to stop the administration of a drug whose staff and EHR had been informed of an allergy consisted of confirming that the medication was never given. No problem, the ED EHR is safe.

(I am not joking; that is the testimony given. Imagine such an investigation and conclusion about, say, reported aircraft flaws, or, in the industry in which I was once a safety officer, public transit vehicle defects and dangers.)

However, when competent people investigate similar issues, the findings are concerning. From Modern Healthcare (http://www.modernhealthcare.com/), a publication for healthcare executives, on the new Annals of Emergency Medicine article:

Electronic health-record systems used in emergency departments are beset with poor data displays, loaded with so many alerts warning of potential patient-safety issues
that they can lead to user alert fatigue, and may be generating
incorrect physician orders, according to a report by two emergency
physicians' study groups.

Meanwhile, providers wanting to address these EHR
issues are hampered by a lack of research and solid evidence of the
extent of the problem with these systems, and by contract provisions
with EHR vendors that stymie the free flow of information about
system-linked safety concerns, the report authors say.

So, ED's across the country are rolling out technology, often taking advantage of ARRA's HITECH incentives ... but there is a lack of research and solid evidence into the risks. Allow me to opine - that's simply crazy.

The groups found that “poor data display is a serious problem with many
of today's EDISs,” while “the sheer volume” of alerts that range from
the “completely irrelevant to life threatening” [or lack of appropriate alerts to relevant, simple issues such as data input errors - ed.] can “dull the senses,
leading to a failure to react to a truly important warning.” They also
found that “an alarming number of clinicians are anecdotally reporting a
substantial increase in the incidence of wrong order/wrong patient
errors while using the computerized physician order entry component of
information systems.”

Two study groups from the American College
of Emergency Physicians have recommended a program of systemic vigilance
over electronic health-record systems used in emergency departments to
improve patient safety and enhance quality of care.

Post marketing surveillance, a standard for decades in other healthcare sectors, has been absent from health IT due to a long-obsolete special regulatory accommodation afforded that industry. This accommodation was initiated when systems were simple and merely advisory - not the comprehensive enterprise clinical resource and clinician command-and-control systems they are today. Now, clinician investigators of the technology such as the authors of this study are realizing that continuing this accommodation is a mistake.

It
follows in the wake of, and references, an Institute of Medicine
report from 2011, “Health IT and Patient Safety: Building Safer Systems
for Better Care.” That report concluded that “current market forces are
not adequately addressing the potential risks associated with the use of
health IT.” It also comes eight months after the New England Journal of
Medicine published “Electronic Health Records and National Patient-Safety Goals,”
which warned that recent evidence “has highlighted substantial and
often unexpected risks resulting from the use of EHRs and other forms of
health information technology.”

I note that if you frequent this blog, you likely read material similar to the bolded red statements above here first, as authored by me, dating to the founding of this blog in 2004.

... “The
rush to capitalize on the huge federal investment of $30 billion for
the adoption of electronic medical records led to some unfortunate and
unintended consequences, particularly in the unique emergency department
environment,” said Dr. Heather L. Farley, the lead author of the
report, in a news release. “The irreversible drive toward EDIS
implementation should be accompanied by a constant focus on improvement
and hazard prevention." Farley is assistant chairwoman of the
Department of Emergency Medicine at Christiana Care Health System in
Newark, Del.

Ironically, I note in Dr. Farley's statement some of my own advice, given to ED staff when I was Chief Medical Informatics Officer at Christiana Care 1996-8. I had in that time period advised Charles Reese IV, MD, Chair of Emergency Medicine, to not implement EHRs or, at best, implement document imaging systems (since ED charts are not that long or complex), not full field-based EHRs, due to the "unfortunate and
unintended consequences" of bad health IT in such an environment I recognized even then. It was only a few years ago that my advice was finally overturned.

The authors also report “(t)here are few consistent
data on how commonly these errors occur, and few studies are actually
focused on collecting evidence of these errors.” Meanwhile, “there is
currently no mechanism in place to systematically allow, let alone
encourage, users to provide feedback about ongoing safety issues or
concerns” with EHRs in general, and EDISs specifically.

On its face, that is not a safety-conscious environment and the rollout and use of such systems seems a fundamental violation of patient's rights, made worse by the fact that there is no informed consent process whatsoever to ED EHR use.

The
workgroups came up with seven recommendations: appointing an emergency
department “clinician champion,” creating within healthcare delivery
organizations an EDIS performance improvement group and an ongoing
review process, paying timely attention to EDIS-related patient-safety
issues raised by the review process, disseminating to the public lessons
learned from performance improvement efforts, distributing vendors'
product updates in a timely manner to all EDIS users and removing the
“hold harmless” and “learned intermediary clauses” from vendor
contracts.

Many of these issues have been discussed on this blog.

“The learned intermediary doctrine implies that the
end users (clinicians) are the medical experts and should be able to
detect and overcome any fallibility or contributing factor of the
product,” the authors said.

They conclude that the “lack of
accountability for vendors through hold harmless clauses and the
shifting of liability to the clinicians through the learned intermediary
doctrine are significant and additional impairments to safety
improvement. Electronic health records and EDISs are sufficiently
complex that the physician and other users cannot be expected to
anticipate unpredictable errors.”

Earlier this month, the
Electronic Health Record Association, an EHR developers trade group
affiliated with the Chicago-based Healthcare Information and Management
Systems Society, announced the launch of a voluntary “code of conduct” in which adherents would agree to drop “gag clauses” in the contracts with their provider customers.

... At this point [of losing the argument], the denialist must propose "self regulation" to deal with the problem that doesn't exist. The cool thing about self regulation is that it cannot be enforced, and once the non-existent problem blows over, the denialist can simply scrap it! [20]

[20] In the runup to passage of bank privacy legislation, data brokers created a group called the "Individual Reference Services Group" that promptly disappeared after the legislation passed.

("Denialism" is the use of rhetorical techniques and predictable tactics to erect barriers to debate and consideration of any type of reform, regardless of the facts.)

IMO 'self regulation' of healthcare is, on its face, a deception. There are simply too many conflicts of interest.

On use of "integrated" big systems:

“These
systems do have glitches [indeed - see http://hcrenewal.blogspot.com/search/label/glitch - ed], but it can be plain and simple bad design
that can lead to clinical errors,” Cozzens said. But ED physicians, he
said, are “having the enterprise systems forced upon them. To think you
can take one system and adapt it to those different environments is
totally wrong. That's why you see low physician satisfaction and the
productivity is going down, all for the sacrifice of having an
integrated system.”

In fact, so-called "best of breed" systems can be bad health IT as well. See the aforementioned evaluation by Dr. Patrick in Australia.

Through my own work, I've seen bad health IT result in patient harm and death. It's just unfortunate that I got started in this line of work by being, in effect, shot out of a cannon. That is, my own mother was a victim.

-- SS

Addendum 10/8/13:

From the article:

End-User Recommendation 4: EDIS-related patient safety concerns identified by the review process should be addressed in a timely manner by ED providers, the EDIS vendors, and hospital administration. Each of these processes should be performed in full transparency, specifically with openness, communication, and accountability.

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